Latent profile analysis of pelvic floor muscle pain in patients with chronic pelvic pain.

AIM: Chronic pelvic pain (CPP) is a syndrome of related diagnoses including pain originating from the muscles of the pelvic floor. The objective of this study was to evaluate which muscles are important to examine, in what manner pelvic floor muscle pain contributes to patients' pain experience, or what thresholds should be applied to identify significant pelvic floor muscle pain by comparing exam findings with outcome measures METHODS: A total of 428 patients meeting the definition for CPP were evaluated using a standardized physical examination of the abdominal wall, pelvic floor, and vestibule along with the 12 domain Patient Reported Outcome Measures Information System (PROMIS). These scores were evaluated for unidimensionality followed by latent profile analysis. The areas under the receiver operator characteristic curves were used to identify the best pain threshold for each muscle. RESULTS: The eight pelvic floor muscle sites all loaded onto a single factor, separate from other areas examined. Two latent classes were found within all the variables. Patients in the severe pelvic floor pain class had significantly worse pain related PROMIS scores. Optimal thresholds for identifying significant pelvic floor pain ranged between 3 and 5. CONCLUSION: Pain in the pelvic floor muscles is distinguishable from pain in the abdominal wall and vulva. Any of the lateral muscle sites evaluated can be used to identify patients with significant pelvic floor pain. Two latent classes of CPP patients were identified: those with limited and those with severe pain, as identified by moderate to severe pelvic floor tenderness.

Phenotyping chronic pelvic pain based on latent class modeling of physical examination.

Introduction. Defining clinical phenotypes based on physical examination is required for clarifying heterogeneous disorders such as chronic pelvic pain (CPP). The objective of this study was to determine the number of classes within 4 examinable regions and then establish threshold and optimal exam criteria for the classes discovered. Methods. A total of 476 patients meeting the criteria for CPP were examined using pain pressure threshold (PPT) algometry and standardized numeric scale (NRS) pain ratings at 30 distinct sites over 4 pelvic regions. Exploratory factor analysis, latent profile analysis, and ROC curves were then used to identify classes, optimal examination points, and threshold scores. Results. Latent profile analysis produced two classes for each region: high and low pain groups. The optimal examination sites (and high pain minimum thresholds) were for the abdominal wall region: the pair at the midabdomen (PPT threshold depression of > 2); vulvar vestibule region: 10:00 position (NRS > 2); pelvic floor region: puborectalis (combined NRS > 6); vaginal apex region: uterosacral ligaments (combined NRS > 8). Conclusion. Physical examination scores of patients with CPP are best categorized into two classes: high pain and low pain. Standardization of the physical examination in CPP provides both researchers and general gynecologists with a validated technique.

The proportion and characteristics of adolescents who return for anonymous HIV test results.

BACKGROUND: The proportion of adolescents who return for HIV test results varies widely, and knowledge of what characteristics affect their return is limited. GOAL: To quantify the proportion of adolescents who return for results of anonymous HIV tests, and to identify the characteristics that predict their return. STUDY DESIGN: This retrospective study evaluated 285 adolescents consenting to anonymous HIV tests in an urban clinic that provides medical services free of charge without eligibility requirements to a mostly working, uninsured population. RESULTS: Of the adolescents studied, 42% returned for test results. Three characteristics independently predicted their return: (1) coming to the clinic only for HIV testing, (2) having private health insurance, and (3) engaging in unprotected sex while using drugs or alcohol. CONCLUSIONS: Except for having unprotected sex while using drugs or alcohol, the characteristics that placed adolescents at risk for HIV infection did not predict their return for test results. Given the low return rate for anonymous testing in this setting, confidential testing, which permits follow-up evaluation of those failing to return for test results, should be considered.

The role of disabled physicians in the diversion of controlled drugs.

To test the assertion that disabled physicians are loose prescribers and clinically meaningful contributors to the diversion of controlled prescriptions, an anonymous survey of physicians in a confidential treatment program in Ohio was conducted to compare pre- and post-recovery: (1) self-reported number of controlled drug prescriptions written, and (2) self-rated appropriateness of prescribing practices. Forty (50%) of the surveyed physicians responded. Opioids alone showed a post recovery reduction in the number of prescriptions (-4.5; 95% CI: -9.5 to -0.5). The volume of prescribing in all controlled drug categories was small from both a law enforcement and clinical perspective. Respondent's self-assessment of prescribing practices indicated conservative pre-, and more conservative post-recovery prescribing, increasing from 2.0 in stimulants (CI: 1.0-4.0), to 3.5 in sedatives (CI: 1.0-6.0). Despite limitations, this initial data provides evidence to refute the assertion that disabled physicians are loose prescribers and meaningful contributors to the diversion of controlled prescriptions.

Prevalence, recognition, and implications of mental impairment among hemodialysis patients.

The increasing age and co-morbidity of dialysis patients may be associated with an increase in the prevalence of Alzheimer's disease, stroke, and other causes of mental impairment. We sought to determine the prevalence, recognition, and implications of mental impairment among chronic hemodialysis patients. We administered the Mini Mental Status Exam (MMSE) to 336 randomly selected patients from three dialysis units. To determine recognition of mental impairment by health care providers, we compared MMSE scores with mental status assessments obtained from each patient's dialysis technician and medical record. To determine the clinical implications of mental impairment, we prospectively obtained Kt/V, albumin, protein catabolic rate, blood pressure, and hematocrit values. To determine the resource implications of mental impairment, we assessed staff time required to care for each patient as well as hospitalizations. We found that 22% of subjects had mild mental impairment (MMSE 18 to 23) and that 8% had moderate-severe mental impairment (MMSE 0 to 17). The sensitivity of technician and medical record mental status assessments were 57% and 15%, respectively. After adjusting for demographic and medical variables, low MMSE score was independently associated with low protein catabolic rate (odds ratio, 1.5; P = 0.02), increased technician time caring for patient after dialysis (odds ratio, 1.5; P = 0.005), and increased hospital days (odds ratio, 1.4; P = 0.03). In conclusion, there is a high prevalence of unrecognized mental impairment among hemodialysis patients that has adverse implications for protein nutritional status, staff time, and hospitalization. We recommend that clinicians routinely screen for mental impairment and target impaired patients for interventions to improve mental status and associated adverse outcomes.